Abnormal uterine bleeding

department of OBS/GYN
Mekelle health science college
melaku abrihaDec, 2009 G.C

Contii
Normal menstrual cycle is menstrual flow as
result of withdrawal of an estrogen primed
endometrium.
Normal menstrual cycle ( 21-35 days, 1-8 days,
10-80ml(average- 30ml) with no pain.
Variation by 3 days from her previous cycle
suggestive of either oligovulation or
esterogenized an ovulation.
Traditional terminology ( menorragia,
metrorahgia, oligomenorrha,
metrostaxis,menometrrorahgia, amenorrhea etc)
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Menorrahgia ( cycle regular, excessive)

Metrorrahgia ( intermensrual bleeding)
Menomterorahgia( excessive irregular bleeding)
Mterostaxis ( more than 8 days)
Olgomenerrhea ( menses greater than every 35 days).
Polymenorrhea ( menses more frequent, than 21 days)
Cryptomenrrha ( normal cycle , decrease flow for
mechanical reasons.
Amenorrhea cessation of menses.
dysmenorrhea( pain during menses)

Conitii..

Diagnosis : the differential

diagnosis for all women
presenting with AUB can
encompassed by the mnemonic
(PHIMIC).
PHIMIC simplifies the approach
and allow the clinicians to cover
vast array of possibilities in the
most efficient and treatment
focused manner.
When a patient present with AUB
its etiology will be found with one
of six broad categories
pregnancy, hormone,iaterogenic,
mechanical, infection and
cancers.

PHIMIC differential diagnosis

I)Pregnancy : should be considered in any women presents
with AUB unless she had hysterectomy or above 60 yrs.
Even women who have had BTL, in their 50 s and have
not menstruating for 1-2 yrs.
Physician will never regret ordering too many pregnancy
tests, but may regret not ordering enough.
Screening for pregnancy is typically accomplished by
using highly sensitive urine pregnancy test, no need of
serum B-HCG.
the two reference preparations currently used are first
and third international reference preparation(detect
antibodies directed to intact HCG).

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The original preparation was the second international
reference preparation(second-IRP) which measured
intact and free HCG, one unit of 2 nd-IRP is
approximately 2 units of 1st & 3 rd IRP.
If B-HCG return above discriminatory zone(abdominal
u/s>6500mu/ml or TV-US > 3600MU/ML, finding empty
uterus is suggestive ectopic pregnancy.
Determination of B-HCG &calculating doubling time
that is 48hrs will help diagnosis of viable versus no
viable pregnancy.
level falling or remaining constant suggestive of nonviable pregnancy.
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II) Hormones : grouped under four
categories.
a)coagulation disorder: von
willibrand,leukemia,ITP aplastic
anemia.
b) hyperprolactinemia
c)thyroid disorders
d)chronic anovulation (hypothalamic,
adrenal ,polycystic ovary syndrome ,
perimenopuse).

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a)Coagulation disorder are most common in girls who are
with in 1 year of first menstrual cycle.
Vonwillbiran disease needs to be excluded on every girls
presenting with excessive AUB with hypovolumic
symptoms.
They should also evaluated for bone marrow
abnormalities, aplastic anemia, ITP.
b) hyperprolactinema is significant cause of AUB, high
level cause alteration of in hypothalamus leading to
decrease level of GnRH leading to ovarian dysfunctions.
it is reasonable to do MRI of sella tursica if level of
prolactin above 60ng/ml.
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In general if prolactin level in excess& pregnancy
desired should be treated with bromocreptine.
If patient desires contraception and there is
microadenoma treatment of choice is OCP.
If patient do not desire contraception ,cyclic
progestin therapy with MEPA 10mg/day for 14 days
every month can be used.
c) a women life time risk to develop thyroid disease
is 15 % and in excess or deficient will affect the
menstrual cycle of the women.
The most common disorder is hypothyroidism
&approximately 2/3 of cases will develop aberration.
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Any women who develop AUB, postpartum
deperssion,premenstrual syndrome should be
screened for thyroid disease. ( TSH, T3, T4, thyroid
scan.
Principal screening is TSH, if TSH is normal no
further studies is needed.
If TSH is high T4 low, thyroxin replacement is the
treatment (25 micro gram per day increase by 25
micro gram every 4 weeks till TSH level normalizes.
If TSH is low hyperthyroidism entertained T3 &T4
tested if one of them elevated do thyroid scan.
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d)The most common hormonal disorder causing AUB is
estrogenized anovulation.(WHO type II anovulation).
A women can present with any thing from complete
secondary amenorrhea to frank hemorrhage.
Therefore characteristics of menstrual flow is of no
diagnostic advantage.
syndromes associated with chronic anovulation can
be grouped in to hypothalamic(CNS) ,adrenal
(adrenal androgen production), ovarian (POCS) or
premenopausal in origin no diagnostic facility to
diagnose exactly.

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PCOS is defined by amenorrhea or oligovulation with
clinical or biochemical evidence hyperandroginmia.
PCOS is best treated by cyclic progesitn,OCP or
clomifene citrate if pregnancy desired.
Insulin sensitizer are reserved for those women in
whom CC has failed &who want to become
pregnant.
another common anovulatory bleeding is
perimenopusal transition, most women experience
5-8 yrs transition from regular menstrual cycle to
frank amenorrhea with interval of AUB.

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The interval is characterized by hypoesrogen state
with symptoms such as hot flush,irritablity, vaginal
atrophy and first sign being shortening of menstrual
cycle.
Premature ovarian failures screened by day -3 FSH
determination.
Two option for treatment are cyclic progestin
10mg(MEPA) for 14 days each month or every other
month.
Best choice for treatment of AUB in perimenopusal is
OCP if the women do not smoke &healthy.( decrease
blood loss, improve symptoms prevent osteoporosis.)
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Use of OCP decrease life time risk of endometrial,
ovarian ca without increasing risk of breast ca.
HRT is reserved for frank menopause is to be
discouraged as it provides estrogen, progesrone
with out affecting endogenous secretions.
III)Iatrogenic cause appears to increase as many
drugs used for cancer, renal transplant causes
AUB.
Physician should inquires prescription history
over the last six months or use of over- thecounter medication.
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Drugs that affects menstrual cycle are
predinsolone, tamoxifen, Coumadin, heparin and
Depo-Provera.
IV)Mechanical : uterine leyomyoma is most common
cause of AUB, sub mucous or interacavitery
myoma causes AUB.
Management extend from OCP, GnRH agonist
myomectomy & hysterectomy.
endometrial polyp are found up to 50% of
presenting as AUB, best diagnosed by
hysteroscopy and SIS (saline infusion sonography)
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V) Infection: is most overlooked causes of AUB/
acute &chronic endometritis can cause AUB.
Endocervicits known cause of AUB particularly
intermenstrual bleeding or postcoital bleeding.
It is prudent to have DNA probing &culture for
gonorrhea &Chlamydia to rule out this
organism as cause of AUB.
due to false negative results for this procedure
it is often wise to treat Chlamydia if no cause
found.
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VI) cancer : endometrial and cervical ca are uncommon
yet very important cause of AUB.
Cervical ca presents with post coital bleeding
&irregular menstrual bleeding.
Even patient has normal pap smear with in previous
yrs it is prudent to reapt pap smear.
Endometrial ca possible in women with AUB above
35yrs.(endometrial biopsy should be done).
therapy of cervical/endometrial ca depend on staging
of disease.
complex endometrial hyperplasia with atypia is
usually managed by simple hysterectomy.
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Other form of hyperplasia is treated with cyclic
or continuous progestin therapy.
Cyclic 10mg MEPA for 14 days each cycle.
Continuous is 20-40 mg MEPA daily for 90 days.
Summery of investigations.
* Hct, blood group/Rh, CBC
* Sensitive pregnancy test.
*vaginal smear /culture &sensitivity
*PT/PTT/ bleeding time( factor viii,VWfactor)
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Pap smear/ endometrial sampling

Ultrasound ( transvaginal)/hysteroscopy
Saline infusion sonography (sis).
CT-scan, MRI imaging
Hormonal profile ( serum prolactin, TFT,
FSH LH level).
Qualitative determination of B-HCG.
DNA probing of Chlamydia infection
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Management of AUB
I) AUB prepubertal girls:
*management is directed to cause, if
symptom persists with discharge suspect foreign
body
* skin lesion, vaginal &ovarian tumor should
be managed by consultation.
II) AUB in adolescent girls : during the first two years it
is anovulatory.
*goal of management is to base therapy on
appropriate diagnosis.
*in the absence of diagnosis the assumption
is that of anovulation or DUB .
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a)Anovulatory mild bleeding :
Mild AUB with normal Hb are best treated by
rest,reassurane &frequent follow up.
Patient with AUB &mild anemia benefit from
hormonal therapy.(low dose OCP used in manner for
contraception)
Alternative is cyclic progesterone(10mg MEPA) for 14
days in each cycle prevent excessive build-up of
endoemetrum by unopposed estrogen.
b) Acute bleeding (moderate): acutely bleeding stable
not requiring hospitalization.

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Requires high dose of hormones that are much
higher than those in OCP.
An effective regimen is patient given 4pills
containing 35 micro gram ethyl estradiol for 4 days
followed tid for seven days, two pills for 11 days
then 1 pill a day there after.
Strong advice need to be given not discontinue it
cause severe recurrent bleedings.
patient should be warned to expect heavy
withdrawal bleeding can be controlled by instituting
OCP 3-6 cycles if women is sexually active others
can be reassured.
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1) After stablization,if careful evaluation
established working dx of anovulation hormonal
Rx control bleeding.
2) Conjugated estrogen, either 25-40mg given IV
every six hrs or 2.5 mg given orally every six
hrs will usually effective.
3) If estrogen is not effective, reevaluate for
mechanical cause ( polyp, myoma).
4) If intrauterine clot detected evacuation clot is
done by MVA or D&C that is better avoided in
adolescent not to compromise future fertility.
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C) acute severe bleeding: hospitalization depend on
rate of bleeding and severity of anemia.
Cause severe menorrhagia is coagulation
disorder(PT,PTT, BT, von willebrnad disease, platelet
disorder &hematological malignancies suspected.
No need of transfusion unless the patient
hemodynamically unstable.
for patient diagnosis of DUB made by exclusion
hormonal therapy makes possible to avoid surgical
interventions( D&C, operative hysteroscopy &
laparoscopy.)

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III) reproductive age group: pregnancy related bleedings
should always be considered as part of evaluation of AUB.
a) Non surgical management:
i) non-hormonal : NSAIDs mefenamic acid &ibuprofen may
show decrease in menstrual flow by 30-50 %.
ii) Hormonal treatment:
* oral contraceptive is well known to control menstrual
bleeding prevent iron deficiency anemia.
* in women in whom estrogen is C/I MEPA, 10mg for 10
days each month can be given
* in Europe some clinician put IUCD containing
norgestral that deliver progestin to prevent bleeding and
pain.
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b)surgical management :
Reserved to situations where medical therapy has
failed or there is contraindications to use it.
D&C some times appropriate both diagnostic and
therapeutic method.
Surgical options range from hyseroscopic,laprascopic
resection of myoma,myomectomy, laser ablation &
hysterectomy.
surgical option rather than hysterectomy should
include a shorter recovery time and less early
morbidities, symptoms can recur or persist.

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IV)postmenopusal age :
Etiology :
* exogenous hormone (30%).
* atrophic vaginaitis/endometritis
(30%)
*endometrial ca (15%)
*endometrial /cervical polyp (10%)
*endometrial hyperplasia (15%)
*miscellaneous (cervical, uterine
sarcoma e.t.c ( 10%)
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Management of atrophic vaginaitis is topical
or systemic estrogen,
Cervical or endometrial polyps can be excised.
Benign hyperplasia ( simple cystic,
adenomatous hyperplasia with out atypia can
be managed by D&C and progestin therapy.
Patient with complex hyperplasia with atypia
treated with simple hysterectomy.
endometrial, cervical or vulvar malignancies
treated based on staging of diseases.
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Thank you !

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